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New York State Report on Pregnancy-Associated Deaths in 2018 - 2020

New York State Report

The New York State Department of Health (Department) would like to acknowledge the 386 New York women who died in the years 2018, 2019, and 2020 within one year of being pregnant, forever affecting their families, friends, and communities. The Department would also like to acknowledge that pregnant people express many different gender identities. The Department is dedicated to learning from their stories and applying the lessons learned to help prevent future deaths for all pregnant people.


Maternal deaths are devastating events with profound and prolonged effects on families and other survivors, as well as a public health issue of critical importance. The United States is one of the only countries in the world that has seen a rise in the maternal mortality ratio since 2000. Black women in the United States die at more than double the rate of White women.1 The number of maternal deaths in New York State and the persistent disparities in the maternal mortality ratio between Black and White women are urgent concerns. In response to this public health issue, the New York State Department of Health (the Department) created the Maternal Mortality Review Initiative in 2010 to perform a comprehensive review of maternal deaths. When the Maternal Mortality Review Initiative was created, New York ranked 46th out of 50 U.S. states for its maternal mortality ratio, a standard measure from the World Health Organization that is based on obstetric death codes indicating a pregnancy within 42 days prior to death. New York State improved to 15th out of 50 states in the most recent ranking.2 According to New York State vital statistics, the 2018-2020 maternal mortality ratio of 19.3 deaths per 100,000 live births was an improvement over the ratio of 24.4 for 2008-2010; the 2018-2020 maternal mortality ratio for Black women was over four times that of White women.3 Public Health Law Section 2509, enacted in 2019, established a Maternal Mortality Review Board, in the Department, to review each pregnancy-associated death.4 Public Health Law also allows the city of New York to establish their own board. The reviews covered by this report were performed by two boards (also known as committees): the New York State Maternal Mortality Review Board reviewed cases of pregnancy-associated deaths that occurred outside of New York City, and the New York City Maternal Mortality and Morbidity Review Committee reviewed cases of pregnancy-associated deaths that occurred within New York City. Section 2509 also established the Maternal Mortality and Morbidity Advisory Council, which is comprised of multidisciplinary experts and lay persons knowledgeable in the fields of maternal mortality, women's health, and public health. Maternal Mortality and Morbidity Advisory Council members serve and are representative of the racial, ethnic, and socioeconomic diversity of the women and mothers of the state. The Advisory Council may review findings of the boards and develop their own recommendations on policies, best practices, and strategies to prevent maternal mortality and morbidity. The committees’ case review efforts are consistent with the objectives of the Prevention Agenda 2019-2024: New York’s State Health Improvement Plan. The Plan aims to implement public health approaches and cross-sector partnerships to reduce, and eventually eliminate, maternal mortality and the associated racial and ethnic disparities in the state.

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